Healthcare Provider Details

I. General information

NPI: 1992411342
Provider Name (Legal Business Name): KRISTIN HUGHES WALTON LCDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 01/30/2023
Certification Date: 01/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 S AUSTIN AVE
GEORGETOWN TX
78626-7541
US

IV. Provider business mailing address

1609 OAK LN
GEORGETOWN TX
78628-3639
US

V. Phone/Fax

Practice location:
  • Phone: 512-819-1100
  • Fax:
Mailing address:
  • Phone: 512-576-9552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16139
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: